By KEN TERRY
Telehealth has been a lifeline for many doctors and patients during the pandemic, and the decisions of CMS and many private payers to cover telehealth visits—in some cases, at full parity with in-person visits–has helped physician practices stave off bankruptcy. Assuming that these policies remain in effect after the pandemic, I agree with the commentators who assert that telemedicine will become a much larger part of healthcare.
Nevertheless, what that means is still far from clear. To begin with, telehealth visits may be adequate for some purposes but not for others. Historically, the technology has been used mostly for diagnosing and treating minor acute problems. Physicians were generally reluctant to take on more complex cases or treat chronic conditions without seeing patients in person.
Pre-pandemic, most telehealth encounters took place between patients and doctors who had never treated them before, using services such as Teladoc, American Well and Doctor on Demand that usually didn’t communicate with the patients’ personal doctors. Some larger physician groups had begun to use the technology with their own patients; but even in those groups, certain doctors were often assigned to conduct virtual visits with patients who were not necessarily their own.
Clearly, the latter barrier has been broken down, with nearly half of U.S. physicians in an April survey saying they were using telemedicine in patient care. While it’s unclear what kinds of cases these doctors are diagnosing and treating, it’s likely that the scope of practice for telehealth has been expanded to include some chronic disease care.
The main barrier to this expansion is that, in telehealth encounters, physicians don’t necessarily have the data they need to make sound medical decisions. To manage hypertension, for instance, the physician needs to be able to measure a patient’s blood pressure. If the patient has a digital blood pressure cuff at home, that data can be transmitted to a physician’s office; in fact, a smartphone app could show the trend of the patient’s hypertension over time. Right now, however, only a small fraction of patients have this kind of remote monitoring equipment.
The other constraint is obtaining lab results on patients, but this is not a problem if patients are willing to visit reference labs during the pandemic. “Virtual health has been great for my diabetic patients,” Donnie Aga, MD, of Houston’s Kelsey-Seybold Clinic, told Medical Economics in 2019. “I know them really well, and they can go to the lab at any time; fasting is not an issue. For routine follow-ups on diabetes, it’s very well done.”
Steven Waldren, MD, vice president and chief medical informatics officer of the American Academy of Family Physicians, told me before the COVID-19 crisis that he expected significant growth in telemedicine, but only if the ability to do the physical exam remotely were improved. If that happens, he said, “The majority of interactions with patients will be virtually done. So, you may have four visits a year from your diabetic patients, but you may have weekly or monthly interactions with them to keep tabs on everything.”
Peter Basch, MD, senior director for IT quality and safety, research, and national health IT at MedStar Health in Washington, D.C., agreed that “micro virtual visits” between in-person encounters will likely become normal in healthcare. After consulting with his colleagues at MedStar, Basch estimated that between 10% and 70% of patient encounters with primary care physicians can be done via telemedicine.
“There are [in-person] visits that are necessary—new patients, people with new episodes of a condition, or who have belly pain or chest pain,” he said. “But what fills up most of my days as an internist are routine follow-ups for hypertension and diabetes and so forth. I need to see your BP and your blood sugar, and if there’s a question, come in.”
Another area where telehealth can benefit patients and increase healthcare efficiency is in e-consults with specialists. Kaiser Permanente has found these virtual consults to be very useful, Richard Isaacs, MD, CEO and executive director of the Permanente Medical Group, told me. For example, he said, if a patient presents with a skin lesion to a Kaiser primary care doctor, the physician can send a secure text message with an image of that lesion to a dermatologist, who will respond as soon as possible.
“It’s all about care without delay,” Isaacs said. “If you have a primary care physician who’s connected immediately to a specialist via smartphone technology, that drives a lot of efficiency.”
While most of U.S. healthcare isn’t organized the way Kaiser is, other organizations have taken a similar approach. The Community Health Center Network (CHCN), a coalition of community health centers based in Alameda, Calif., offers e-consults to its primary care physicians. Doctors send questions with relevant patient histories to a specialist network, and an appropriate physician responds within four hours. A study of CHCN e-consults found that 25% of virtual visits were resolved without requiring an in-person visit to the specialist.
Fee for service system
Of course, the fee for service system will remain an obstacle to the widespread use of telemedicine even after the pandemic is over. For one thing, most specialists would rather bill for an in-person visit than provide an e-consult to a primary care physician. Primary care physicians also can’t earn as much via telemedicine as they can with in-person visits, even if the two are reimbursed at the same rate. In part, that’s because telehealth doesn’t allow them to provide the vaccinations and minor procedures that they customarily do in the office. Moreover, some groups own labs that they refer patients to during office visits.
If primary care physicians were paid capitation instead of fee for service, they wouldn’t be able to bill for these services, either. But at least they’d have a steady stream of income, which would protect their practices during the pandemic. In addition, if the capitation rate were set at an appropriate level, it could make up for the loss of income for ancillary services. And it would encourage between-visit care, which is indispensable in treating chronic conditions
Much will change in healthcare after this crisis is past, including the expanded use of telehealth. But to take full advantage of the beneficial changes, we must plan them intelligently.